Healthcare Provider Details

I. General information

NPI: 1275565970
Provider Name (Legal Business Name): CAROLYN JENNINGS SOUTHWORTH D.M.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. CAROLYN JENNINGS

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 HIGH POINT CT SUITE 200
MOUNT WASHINGTON KY
40047-6563
US

IV. Provider business mailing address

209 HIGH POINT CT SUITE 200
MOUNT WASHINGTON KY
40047-6563
US

V. Phone/Fax

Practice location:
  • Phone: 502-538-6555
  • Fax: 502-538-0657
Mailing address:
  • Phone: 502-538-6555
  • Fax: 502-538-0657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8324
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: